Lord Lipsey: My Lords, like the noble Lord, Lord Kakkar, I sit on the Select Committee on the sustainability of the health service, chaired by the  noble Lord, Lord Patel. Last week, I came out of St Thomas’ Hospital, where I had had a TAVI—an operation on a heart valve—to sit down to the backlog of papers from the committee. The first paper I picked up said quite clearly that unnecessary treatments should be eliminated—for example, TAVIs, which are completely ineffective. All I can say is, in that case I have had the mother and father of a placebo effect.
I mention this simply to say that in the general gloom that so easily pervades debates on our health service, we can forget what it is really like. My experience was marvellous—clinical marvellousness, caring marvellousness—and I was in and out, after a general anaesthetic, within three days. So let us not play down what our health service is delivering. It is because it delivers these things that it is so precious and our people will never let it go.
I am very grateful to my noble friend Lord Hanworth for introducing this debate. I think he sometimes got a little carried away with his own rhetoric. The moment at which he accused the party opposite of cunning concealment by putting their proposals in a pamphlet struck me as one example. In general, I cannot share his view of the 2012 Act and its consequences any more than I can share that of the Secretary of State who introduced it. My take is that only three years have gone by since its provisions came into force and it is clearly too early to form any sort of verdict, particularly since there is a much more important effect, which is the amount of spending that is taking place and the staff and resources available. It is far too early.
However, Sir Muir Gray of Oxford University, a most distinguished witness who appeared before our committee on Tuesday, said:
“I speak as a veteran of 22 re-organisations, most of which have made no difference at all”.
I expect that this one will be broadly the same. Talking to people who understand, work in and know the work of the health service, there is a consensus that it works not because of the Ozymandian bureaucracies erected by Governments—and endorsed by Parliaments, let us remember—but in spite of these bureaucracies, which mostly serve only to add cost and complexity.
I will say a word or two about the sustainability of the health service. This language has become embedded in all sorts of work. We even have sustainability and transformation plans—words which fill me with gloom at their lack of transparency. The trouble with sustainability is that it suggests black or white. We either have a health service that works or a health service that has collapsed, in which case we have to have a new system: private healthcare as in America, a Bismarckian system as in Germany, or whatever. But, of course, it is not like that at all.
First, we have to ask what it is about the health service that has to be sustained. A phrase that is trotted out as if it were obvious the whole time is, “free at the point of use”. We do not have a health service that is free at the point of use. Lots of healthcare is paid for, as the noble Lord, Lord Colwyn, made clear in his speech on dentistry. We have north of £500 million of prescription charges—which, incidentally, are becoming quite a barrier to some people taking the care they   need—for across-the-counter medicines. John Appleby of the Nuffield Trust suggested to the committee that private spending on health in this country amounted to 1.5% of GDP. It is not as big as public spending, but it is a pretty big chunk. So let us be clear that there is a wide range of “free at the point of consumption”.
Another phrase is “a national health service”. We do not have a national health service. The provision of specific treatments varies hugely from place to place, in a way that is very difficult to account for—factors of fourfold and even tenfold, as Sir Muir explained to our committee. Different social classes get widely different provision and as a result have widely different expectations of life. For example, in some areas 78% of people die at home and in others 46%; that is the range of experience.
There is a more sensible way of looking at sustainability. Somehow or other, the supply and demand for healthcare has to be balanced—that is inevitable. The main factor affecting supply is how much money the Government, and by extension society—taxpayers—are prepared to raise to pay for it. Healthcare is a menu with prices and we can imagine a health service in which people can choose only thin gruel and one which provides caviar for all. It depends almost entirely on how much money people are prepared to put in.
The real question is therefore not whether we have a health service that is sustainable, but what kind of health service we want. When we have decided what we want, are we prepared to pay for all of it, some of it, or rather little of it? Importantly, how can we get the maximum of what we want for the minimum we put in? I am afraid that those people who think there is a magic wand that can be waved and surgeons can double the number of operations they do in five minutes are barking up the wrong tree. From these core questions, the 2012 Act was essentially a distraction. I hope your Lordships’ committee may do a little better.